13 June 2008

There are some patients that you dread having to see. You just know in your heart before walking into the room, that it's going to end up badly -- an argument, a dispute over narcotics, a complaint to administration, something bad -- despite all your efforts to make nice. I saw her name on the chart when I picked it out of the rack, and my shoulders slumped as I recognized the name. I wondered momentarily whether anybody had seen me pick up the chart -- maybe I could slip it back in the rack for my partner to take. But my conscience wouldn't permit that, so I took a deep breath and squared my shoulders, and went bravely into the room.

This lady had a lot of problems. She was terribly addicted to narcotics, on well over 160 mg of oxycontin daily, had intractable headaches, anxiety problems, heart problems, abdominal pain with no clear diagnosis, and all sorts of other psychiatric issues. A challenging patient. What was she here for today?

"Doctor, I'm getting bruises all over for no reason," she said, extending her arm towards me as evidence. "I just started a new blood thinner and I read on the internets that if you have bruising to go to the ER immediately!"

Sure enough, she did have a bruise around her right wrist. It looked as if someone had grabbed her where her gold bracelet was and squeezed really hard. But she denied any trauma. Despite her statement, she really didn't have any bruises anywhere else. I inspected the bruise a little more carefully.

There was no swelling, but the purple-green coloration was pretty typical of an evolving deep bruise. I pulled at the skin a bit, and the bruise moved with the skin, which was a little unusual; generally you can pull the skin across the underlying bruise. This looked like it was in -- or on -- the skin. On a hunch, I got a wet paper towel and rubbed the bruise a bit.

She was horrified, embarrassed, and delighted all at the same time. She covered her face in mortification, and thanked me effusively for being "clever" enough to figure it out. Since she was now cured, I told her she could go home, hoping to get her discharged in that brief window of relief, before she could dream up another complaint. She was so embarrassed that she bolted the ER without even waiting for discharge instructions.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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